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Chapter 10: Children 105
Key points
Normal IAP in mechanically ventilated children is about
7 mmHg.
Critical values of IAP that suggest IAH and ACS are lower in
children.
In children, IAP greater than 10 mmHg should be
considered to be IAH.
IAP above 10 mmHg associated with new organ dysfunction
is ACS in children until proven otherwise.
Abdominal breathing in children may result in erroneous IAP
readings.
FURTHER READING
Ejike JC, Bahjri K, Mathur M. What is normal intra-abdominal
pressure in critically ill children and how should we measure
it? Critical Care Medicine 2008; 36: 2157–62.
Ejike JC, Humbert S, Bahjri K, Mathur M. Outcomes of children
with abdominal compartment syndrome. Acta Clinica
Belgica Supplement 2007; 1: 141–8.
Ejike JC, Kadry J, Bahjri K, Mathur M. Semi-recumbent position
and body mass percentiles: effects on intra-abdominal
pressure measurements in critically ill children. Intensive
Care Medicine 2010; 36(2): 329–35.
Chapter 11
Trauma
Introduction
Occurrence of ACS is not limited to abdominal trauma patients.
Secondary ACS can be a frequent complication in severely
injured patients if IAH is not prevented. All patients sustaining
severe trauma, irrespective of its location, are at risk of
developing IAH and ACS. Prevention of secondary ACS is
possible by the application of ‘damage control’ surgery,
judicious fluid resuscitation and adherence to specific
transfusion protocols.
In patients requiring ‘damage control’ surgery, leaving the
abdomen open is a key element in preventing ACS. When
ACS develops in trauma patients, early decompression is
advised. After decompression, non-surgical measures will allow
early abdominal closure.
Organ dysfunction is a marker of development of IAH
and ACS.
Types of ACS in trauma patients
Both primary and secondary ACS are commonly seen in
trauma patients.
Chapter 11: Trauma 107
The usual presentation of primary ACS is severe abdominal
trauma requiring ‘damage control’ laparotomy with (or
without) packing and abdominal closure. While the abdominal
trauma is the direct cause, mechanisms leading to secondary
ACS such as fluid resuscitation contribute to further
deterioration.
All types of extra-abdominal trauma can lead to secondary
ACS. Secondary ACS usuallydevelops later than primary ACS but
should be considered at any time if organ dysfunction develops.
This may happen within the first 12 hours after injury, and
IAP monitoring is always indicated in severely injured patients.
Incidence
The incidence of IAH and ACS in trauma patients is decreasing
rapidly as centres have embraced these concepts and apply
strategies that avoid the occurrence of both primary and
secondary ACS. A few years ago, the incidence of ACS was as high
as 40% with high mortality rates. It has reduced dramatically
in recent years. The occurrence of ACS in trauma patients is now
considered an indicator of suboptimal trauma care.
The ‘bloody’ vicious circle and IAH
The ‘bloody vicious cycle’ or ‘lethal triad’ of trauma patients is
the combination of coagulopathy, hypothermia and acidosis.
These three factors contribute to ongoing blood loss from
the injured body. Ischaemia/reperfusion injury occurs at the
initiation of resuscitation.
108 Section 3: Specific conditions: when to worry more?
Early control of blood losses and restoration of the
coagulation capabilities of the blood are important in avoiding
this lethal triad. Resulting oedema (inside and outside the
abdominal cavity) will result in IAH. Strategies aimed at
preventing this lethal triad will effectively prevent ACS.
‘Damage control’ surgery aims at early and rapid control of
blood loss. Prophylactic open abdomen management is an
early step. Rapid transfer of the patient to an intensive care
unit to correct acidosis, hypothermia and coagulopathy is
essential. Definitive repair of non-life-threatening injuries can
be delayed to a later stage.
It is often difficult to distinguish ACS from shock, continuous
bleeding and related inflammatory responses. To help
differentiate between these, IAP measurement is required early
in trauma patients.
Predicting factors of IAH in the trauma patient are shown in
Table 11.1.
Table 11.1 Predictors of ACS in trauma patients
Primary ACS Secondary ACS
Temperature <34°C Administration of >7.5 L of crystalloids before
ICU admission
Haemoglobin <8 g/dL No indication for life-saving surgical intervention
Base deficit >8 mmol/L Relatively low urine output (<50 mL/h)
Administration of >3 L of
crystalloids
Transfusion of ≥3 units of
red cells
Need for emergency surgery
Poor intestinal perfusion measured by gastric
tonometry
Chapter 11: Trauma 109
Conservative management of the patient with abdominal trauma
Conservative management of the trauma patient does not
mitigate the risk of IAH and ACS. Patients may have lost
considerable amounts of blood in the peritoneum, and other
factors (such as oedema formation due to shock from
extra-abdominal injuries or ileus) may contribute to the
development of IAH. These mechanisms explain why IAH can
happen in patients treated with angiographic embolization.
Laparotomy is the definitive treatment option if residual
bleeding from the initial injury persists. Reports of successful
percutaneous drainage using large bore catheters are
encouraging.
Similar to patients with severe acute pancreatitis, trauma
patients who develop secondary ACS may benefit from a
subcutaneous linea alba fasciotomy (SLAF). This is an attractive
alternative in patients who did not require an initial
abdominal surgical intervention.
IAH in the patient with an open abdomen
The risk for ACS in patients with an open abdomen is low but
new issues (such as bleeding) may lead to an increase in IAP.
A midline laparotomy may be inadequate (too small) to
decompress the abdomen fully.
Moreover, IAP can decrease after abdominal decompression
but still remain above the threshold for continued damage to
various organ systems. Medical strategies to decrease IAP
110 Section 3: Specific conditions: when to worry more?
further are important to reverse organ dysfunction. An open
abdomen is just one element in the treatment, and does not
preclude the development of IAH and ACS.
The abdomen should remain open as long as this benefits the
patient, but attempts should be made to close the abdomen
early. A fine balance is required. Continued IAP measurement
is indicated to help make the right decision.
Key points
IAH and ACS can occur both in abdominal trauma and
extra-abdominal trauma patients.
Patients at risk for IAH should be identified at an early stage of
their treatment.
IAP must be measured regularly in all severely injured
patients irrespective of the site of injury.
Early bleeding control and avoiding massive transfusion are
key elements in preventing IAH in trauma patients.
Open abdomen treatment should be applied liberally in
patients at risk.
The use of medical management strategies to reduce IAP
will facilitate early closure of the abdomen, and avoid
complications related to open abdomen treatment.
FURTHER READING
Ball CG, Kirkpatrick AW, McBeth P. The secondary abdominal
compartment syndrome: not just another post-traumatic
complication. Canadian Journal of Surgery 2008; 51: 399–405.
Chapter 11: Trauma 111
Cheatham ML, Safcsak K. Is the evolving management of
intra-abdominal hypertension and abdominal compartment
syndrome improving survival? Critical Care Medicine 2010;
38: 402–7.
Rizoli S, Mamtani A, Scarpelini S, Kirkpatrick AW. Abdominal
compartment syndrome in trauma resuscitation. Current
Opinion in Anaesthesiology 2010; 23: 251–7.
Chapter 12
Burns
Introduction
Severe burn patients develop IAH/ACS within 48 hours.
The increase in capillary permeability contributes to
extensive oedema formation and intraperitoneal
accumulation of fluid. Gut oedema and fluid translocation
is worsened by venous hypertension caused by an
elevated IAP.
Figure 12.1 shows the relationship between the
resuscitation fluid volume received within the first 24 hours
of the insult, the percentage of the total body surface area that
has been burned and ACS.
Secondary ACS in burn patients generally occurs within
48 hours of the injury, during the initial resuscitation
period. The risk decreases substantially when the patient
reaches the ‘diuretic phase’. The risk for IAH/ACS increases
again if the patient develops sepsis.
Incidence
The incidence of IAH depends on the severity of the burn
injury. The risk of ACS is directly related to the burned area.
Intravenous Fluid Volume (mL/Kg/24h) Total Body Surface Area (%)
600
500
400
300
200
100
0
50
100
Figure 12.1
Chapter 12: Burns 113
Individual Case
Consequences of IAH in the patient with severe burns
IAH is associated with impaired organ dysfunction, including
the cardiovascular, respiratory and renal systems. In severe
burn patients, the kidneys become vulnerable and preserving
renal function is particularly important. ACS alone, or when
associated with its surgical treatment, increases the risk of
multiple organ dysfunction, including acute lung injury. The
mortality rate of patients developing ACS is 50–80%, even
when treated.
114 Section 3: Specific conditions: when to worry more?
Monitoring IAP in the burn patient
IAH/ACS should be considered in all patients with severe
burns. IAP measurement should be performed every 2–4 hours
throughout the resuscitation period in burn patients with more
than 20% of their body area affected.
IAH/ACS might occur in patients without circumferential
third degree burn of their trunk. Figure 12.2 shows a patient
with a tense abdomen despite normal elasticity of the
abdominal wall. Measurement of the IAP revealed a pressure
of 60 mmHg.
Figure 12.2